Every-other-night home hemo - journal articles?

A nearby facility offers home hemo on an every-other-night schedule (with monitoring) and we are trying to get our facility to also offer this service but our nephrologist wants to see journal articles that specifically support this schedule. Are you familiar with any studies that have been done on this schedule? I’ve checked the list of articles on this site and on nocturnaldialysis.org and find articles on 5 or 6 night-per week dialysis, but none on every-other-night. Thank you.

When nocturnal dialysis, in its modern format, was popularised from the work of Pierratos and Uldall from Toronto in the early 1990s, many of the early nocturnal programs that developed from their experience, including our own here in Geelong, and that of Lockridge in Lynchburg, West Virginia, took their lead from Pierratos and developed 5 to 6 night per week, slow, overnight dialysis systems.

Pierratos, however, developed the Toronto program based on the long experience of Charra and Chazot from Tassin, France, where three night per week overnight long and slow dialysis had been practised continuously from the 1960s. Indeed, the Tassin experience is the longest, most sustained and by far the most published experience of overnight dialysis anywhere in the world. Tassin has reported the best outcomes, bar none, recorded anywhere in the world. What’s more, they have sustained these outcomes for over 4 decades.

The Tassin program has always been a three night per week program. It has always been in-centre and it has still had a ‘long break’ … that 3 day hiatus between dialysis treatments – commonly Friday through to Monday or Saturday through to Tuesday … inbuilt into their model. Despite this long-break disadvantage, the Tassin model has remained the ‘base model’ upon which all other nocturnal programs have been developed. And, despite the long-break disadvantage, Tassin remains the ‘outcome’ beacon for us all.

Although the Pierratos model of a 5 to 6 night per week, home-based overnight program that we adopted here in Geelong was certainly the early favoured system, it became apparent that home patients could satisfactorily manage with an alternating nightly program … if you like, seven treatments every two weeks or, as most dialysis regimens are geared to reference the number of treatments per week, 3.5 treatments per week. Obviously, no one has ½ treatments – or 3 ½ treatments a week – 3.5 treatments per week is simply a shorthand way of saying 7 treatments every two weeks or, by intent, alternate day (or night) dialysis.

In Australia, where nocturnal home-based dialysis is more common than anywhere else in the world, most of our national programs have adopted the alternate night approach. However, here in Geelong we have continued to encourage our patients to do more – and most of our patients still do between 5 and 6 nights a week. However, the majority of Australian units support and do very well with alternate night therapy.

In Australia, dialysis is free for all. Home dialysis is encouraged. Home dialysis is incentivised. Home installation, water plant, machine – all the consumables, everything – is covered for patients and although there remain a few home patient out-of-pocket expenses that we are working to remove, compared to elsewhere, our home patients are well supported

Is there a difference between 3, 3.5, 4, 5, 6 or even 7 (yes, some do 7) nights/week? Is one frequency better than another? Who or what is right?

The difference between any overnight program (where dialysis continues for between 8 and 9 hours) and any day-based program (where dialysis duration is usually limited to between 4 and 5 hours) appears far, far greater than the difference between any overnight program, whether run on alternate nights or run for 4, 5 or 6 nights.

The reason for this difference is simple – volume control.

Solute removal is so efficient with long slow treatment that, although I personally believe that a higher frequency is better, the issue of solute removal pales against that of fluid removal.

I have dealt with both the removal of solute and the removal of fluid in previous discussions, both here in earlier posts and in the Webinars that I ran for HDC during 2009. You will find these at the bottom of their homepage http://www.homedialysis.org and you can replay them in your own time.

Studies comparing dialysis regimens – particularly ‘randomised control trials’ (called RCTs) – are almost non-existent.

There are a myriad (and I mean a myriad) of observational studies which have, to a fault, confirmed advantage for any form of longer, slower or more frequent therapy over standard conventional dialysis as we know it. Carl Kjellstrand has painstakingly collected and documented these and he stopped counting at 650! … and that was back in 2008!

But as for RCTs, only one decent one has ever been completed. It was by Bruce Culleton, and the Calgary group. It was published a couple of years ago and demonstrated significant advantages to nocturnal dialysis. Their study has been much discussed and commented upon and I will not deal with the detail here, except to say that it demonstrated a significant reduction in left ventricular hypertrophy (the thickness of the heart wall – ‘thick’ is bad), a significant improvement in left ventricular function, better blood pressure control, less blood pressure medication and a significant improvement in several quality of life measures in the patients who were randomly allocated to long, slow, frequent overnight dialysis in comparison to those patients who were randomly allocated to conventional therapy.

An RCT is almost impossible to conduct, however, in a lifestyle-dependent therapy like dialysis. A set of unique and serendipitous circumstances allowed Bruce to perform his study but these are difficult to duplicate in a trial situation and the randomization of patients to different dialysis modalities is a very complex thing to do. As a result, it is very hard to get enough people into any study to get enough numbers in the study to show any convincing statistical difference.

Just imagine being told: “you are going to go home on 6 nights a week dialysis” … ‘but I don’t WANT to go home – and I live on the 33rd floor’ … or, “you are going to stay in-centre on 3 days a week short hour dialysis” … ‘but I really WANT to go home – and travel time to the nearest centre is 3 hours!’

We reported a comparison, some 5 years ago, between our Geelong 6 nights a week nocturnal patients and those of Peter Kerr’s unit at Monash, where alternate night nocturnal therapy was the more common approach. Kumar Mahadevan, our ‘registrar’ at the time (we call our ‘fellows’ by the term ‘registrar’) was the lead author.

You will find this paper referenced at my website – http://www.nocturnaldialysis.org. It was published in Nephrology, the Journal of both the Asia Pacific Society of Nephrology and Australian and New Zealand Society of Nephrology (the Journal in which we publish most of our papers)
Mahadevan K, Pellicano R, Reid AB, Kerr PK, Polkinghorne KR, Agar JWM, Comparison of biochemical, haematological and volume parameters in two treatment schedules of nocturnal home haemodialysis. Nephrology (Carlton) 11(5), 413-418, October 2006.

In this study (and, yes, it was yet another a small, retrospective, observational study) we concluded that while the 6 night per week nocturnal patients had better volume control, better blood pressure control and better medication outcomes, the biochemical parameters were similar between the two groups. If anything, the alternate night group did better with phosphate. Indeed, the phosphate removal in the 6 nights a week dialysis patients is so efficient that phosphate replacement is necessary for most while, with alternate night dialysis, phosphate removal seems to be pretty much ‘on the money’ – binders can often be withdrawn yet phosphate replacement is often not required.

To my knowledge, this is the only comparative study that has ever been done - demonstrating the difficulty of cross comparisons between dialysis regimens.

You will, however, find several references to alternate overnight dialysis. Simply plug into your browser these three words – alternate, night, hemodialysis.

You will also find a review of how home dialysis is done in other parts of the world at a paper I wrote for ACKD last year

Agar JWM. International Variations and Trends in Home Dialysis. (Requested Paper): Advances in Chronic Kidney Disease. 6(13): 205-214, May 2009

And http://ndt.oxfordjournals.org/cgi/content/abstract/20/2/285 for Francesco Locatelli’s discussion of dialysis dose and frequency.

These are but a few of the massive literature now available on the topic.

For the benefit of your nephrologist, there is absolutely nothing unusual about alternate night programs. I cannot understand why there would be any uncertainty about this. This is particularly so as many of the chain dialysis systems in the United States – Fresenius, DaVita etc – already routinely offer 3 night a week in-centre programs.

The clear advantage of an alternate night program is that it does away with the long-break and it would be the single most significant forward step the US could take if, or when, the US nocturnal program chains adopt an alternate night model, rather than the 3 night a week model they currently offer.

At the end of the day, alternate night therapy is a very, very good way to go. Not, mind, as good (in my view) as more frequent regimes … but very, very good all the same.

It builds on the Tassin experience.

It eliminates the single most important deficiency in the Tassin program – the long break.

It avoids the cost implications of more frequent dialysis regimens.

It lessens the potential for infective risk that more frequent fistula access requires in the frequent dialysis programs and that have raised some concern in some quarters about such programs.

Though I still have strong reasons for arguing the case for more frequent dialysis – and I will continue to do so – I know that many of my colleagues here in Australia believe alternate night therapy offers an excellent compromise … and, yes, it is a compromise … between, on the one hand, far better solute clearance, reasonably sound volume control and the abolition of the long break, and on the other hand, good fiscal management and cost control.

Though I believe more dialysis is better dialysis, and I will continue to believe that and argue for it, with cost containment a very real issue for service providers and governments, the enormous and ongoing cost benefits of any form of home dialysis – be it 3, 3 ½ , 4, 5, 6 or even 7 days or nights per week – make home programs a win/win outcome for patient and provider alike.

John Agar

Thank you so much for this very thorough response!